Principal Duties and Responsibilities:
• Adjudicate claims to pay, deny, or pend as appropriate in a timely and accurate manner according to company policy and desktop procedure.
• Review and research assigned claims by navigating multiple systems and platforms, then accurately capturing the data/information necessary for processing (e.g., verify pricing/fee schedules, contracts, Letter of Agreement, prior authorization, applicable member benefits).
• Manually enters claims into claims processing system as needed.
• Ensure that the proper benefits are applied to each claim by using the appropriate processes and desktop procedures (e.g., claims processing policies, procedures, benefits plan documents).
• Communicate and collaborate with external department to resolve claims errors/issues, using clear and concise language to ensure understanding.
• Learn and leverage new systems and training resources to help apply claims processes/procedures appropriately (e.g., online training classes, coaches/mentors).
• Meet the performance goals established for the position in areas of productivity, accuracy, and attendance that drives member and provider satisfaction.
• Create/update work within the call tracking record keeping system.
• Adhere to all reporting requirements.
• Keep up to date with Desktop Procedures and effectively apply this knowledge in the processing of claims and in providing customer service.
• Identify and escalate system issues, configuration issues, pricing issues etc. in a timely manner.
• Process member reimbursement requests as needed.